Provider Demographics
NPI:1538129408
Name:PHYSICAL THERAPY CLINIC OF LAFAYETTE, INC.
Entity Type:Organization
Organization Name:PHYSICAL THERAPY CLINIC OF LAFAYETTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-232-7080
Mailing Address - Street 1:1432 S COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2912
Mailing Address - Country:US
Mailing Address - Phone:337-232-7080
Mailing Address - Fax:337-237-2517
Practice Address - Street 1:1432 S COLLEGE RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2912
Practice Address - Country:US
Practice Address - Phone:337-232-7080
Practice Address - Fax:337-237-2517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5C579Medicare PIN